Peduncular Hallucinosis: an Unusual Case of Visual Hallucination in a Delirious Patient

Elmer Press Case Report J Med Cases • 2013;4(3):176-178

Peduncular Hallucinosis: An Unusual Case of Visual Hallucination in a Delirious Patient

Krishnendu Ghosha, b, Guitelle St. Victora

ing the cause of this extremely distressful symptom cannot Abstract be overemphasized. In the case mentioned below, visual hallucination was found to be caused by a rare condition called Visual hallucination is very common in case of delirium and other peduncular hallucinosis, in a patient who presented with al- neuropsychiatric disorders. It is one of the most common clinical tered mental status. symptoms for which psychiatric consultation is requested on medical floors. When hallucination dominates the clinical presentation, a patient may be misdiagnosed as suffering from a psychiatric dis- Case Report order. This case is a wonderful example of Peduncular Hallucino- sis, an underlying organic pathology. A possible pontine tumor was discovered in a patient admitted to the medical floor with altered We report here the case of a 77-year-old African American mental status in the absence of any focal neurological signs. female with past medical history of Hypertension but no prior psychiatric history. She was admitted to the medical Keywords: Visual hallucination; Peduncular hallucination; Mag- floor with altered mental status. She was reported to have netic resonance imaging been found in a state of confusion by her family. The patient had no history of head trauma, loss of consciousness, seizure, and fever or chest pain. Her past ophthalmological history was remarkable for cataract and glaucoma. The pa- Introduction tient reported visual hallucinations for five to six days. She had been seeing cats, dogs and small children that she knew When a patient presents with visual hallucination in the ER, were not real. She reported often seeing two of an item: a we first consider the most common conditions like delirium, hallucinatory dog playing alongside of her real dog, and a dementia or psychosis. Visual hallucinations can originate child who did not really play with her great granddaughter. from a variety of psychiatric, medical, neurologic, ophthal- Sometimes she would see a man sitting on a chair next to her mologic and metabolic disorders. A study done in a geriatric but he would not talk when she addressed him. She denied psychiatric clinic found that 10% of the clinic patients expe- any auditory or other types of hallucinations. According to rienced visual hallucinations [1]. A classic study of delirium, the patient, she had no history of hallucination prior to these by Wolff et al [2] noted that visual hallucinations were pres- experiences. She denied any symptoms of mania, psycho- ent in 67.9% of delirious patients. Another study by Webster sis or any other anxiety disorder. She felt concern about her [3] showed that 27% of patients with delirium experienced symptoms but denied neural vegetative symptoms of depres- visual hallucinations. The importance of correctly identify- sion per se. The patient had some evidence of slight cogni- tive decline, memory impairment, visuopatial impairment, and verbal fluency impairment. However, this did not affect her activities of daily living. The patient said that she real- ized driving was not safe, and hence she stopped driving. The patient’s husband died three years ago of cardiac arrest. Manuscript accepted for publication September 24, 2012 The patient had 5 children, the oldest two of which were de- ceased following drug overdoses in 1986 and 1989. After her aVon Tauber Institute of Global Psychiatry, Department of Psychiatry and Behavioral Science, Nassau University Medical Center, NY, USA daughters passed away, the patient took in their nine children bCorresponding author: Krishnendu Ghosh, 200 Carman Avenue, Apt and raised them as her own. The patient reported abusing 30 A, East Meadow, NY, 11554, USA. Email: [email protected] alcohol from age 13 through 30 but indicated that she had been sober since age 30. She denied use of any other recre- doi: http://dx.doi.org/10.4021/jmc868w ational drugs. Patient worked as an administrative assistant

176 Articles © The authors | Journal compilation © J Med Cases and Elmer Press™ | www.journalmc.org 177 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Ghosh et al J Med Cases • 2013;4(3):176-178

98 mg/dL, BUN 11 mg/dL, and Creatinine 0.9 mg/dL. LFT’s showed ALT 17 U/L, AST 20 U/L, Alk Phos 92 U/L, and to- tal bilirubin 0.3 mg/dL. Coagulation Profile showed PT 12.9 secs INR 1.0, and PTT 30.2 secs. MRI of the brain stated mild involutional changes. There were scattered foci bright signal intensity on the T2 and flair images in the periventricular and deep white matter, which could be because of ischemic-gliotic changes. No mass lesion was seen. Specifically there was a bright signal intensity within the left portion of the pons. The craniovertebral junc- tion was unremarkable (Fig. 1). MRA of the brain was normal. Neurology consultation addressed this as peduncular hallucinosis, with possibility of Glioblastoma multiforme in the pons. Neurology team advised MRI with contrast study to rule out any malignancy. Neurology also advised to follow-up in the neurology clinic but unfortunately patient did not show up in the clinic and lost contact. Figure 1. MRI of the brain showing scattered foci bright signal intensity on the T2 and FLAIR images in the periventricular and deep white matter, there was bright signal intensity Discussion within the left portion of the pons. Visual hallucinations are caused by transient increased activity in the visual cortex. In case of visual hallucinations, until she retired. Patient denied having a family history of the most important question arises to localize the lesion in any psychiatric disorder. the brain. There are two main types of visual hallucinations, At the time of the interview the patient was comfortable, formed and unformed. Unformed hallucinations consist of well groomed and appeared to her stated age. She was alert blotches of color, geometric shapes, flashing lights, or some and oriented to time, place and person. She was cooperative other ill-defined images. Formed hallucinations, on the other with good eye contact. Speech was spontaneous and well-ar- hand, consist of well-defined objects, people, animals, or ticulated. She described her mood as slightly depressed. Her anything else. It is easy to figure out what type is being expe- affect was stable and mood congruent. No delusions were rienced by a patient, simply from their description. An occip- elicited. She denied any suicidal or homicidal ideation, intent ital lobe focus produces lights or colors, whereas temporal or plan. Her insight was fair and judgment was appropriate. lobe focus results in complex formed images [4]. The causes Her attention and concentration were moderately impaired of formed VH include: 1) ocular pathology like macular de- as well as her short term memory. The C-L team recom- generation, cataract; 2) peduncular origin, or 3) cholinergic mended MRI of the brain, and Opthalmology and neurology in nature as seen in Parkinsonism. Our patient had distinctive consultation to rule out Charles-Bonnet syndrome. a pontine lesion along with visual hallucination, which is the Her general physical examination as per the primary hallmark of peduncular hallucinosis. medical team and her Neurological examination as per the L’hermitte first described the clinical syndrome of pe- Neurology team were unremarkable. Ophthalmological ex- duncular hallucinations, but Von Bogaert coined the term amination showed a Visual Acuity of 20/150 in the Right eye “peduncular hallucinations”. Peduncular hallucination has and 20/100 in her left eye with bilateral open angle glaucoma been reported because of vascular and infective lesions of and cataract. Patient did not have any other ocular pathology the thalamus, the pars reticulata of substantia nigra, mid- and the ophthalmology team recommended management brain, pons and basal diencephalon. It could be due to com- of cataract and glaucoma on an outpatient clinic basis. The pression of midbrain. The etiology of the hallucinations in patient’s CT scan showed mild involutional changes along peduncular hallucinosis is still unknown, but causes can be with ischemic-gliotic changes, without any acute intracra- vascular stroke, encephalitis, neoplastic changes, intoxica- nial pathology. Her blood tests were followed: Complete tion, vertebral angiography and transient brain stem com- blood count showed WBC 10.7 K/mm3, Hemoglobin 14.8 pression [5-6]. Feinberg [7] and Mackee [8] explained more g/dL, Platlet189 K/mm3. Comprehensive metabolic profile anatomically that occlusion of the paramedian branches of showed Sodium 141 mmol/L, Potassium 4.3 mmol/L, Chlo- the rostral basilar artery causes infarcts in the medial dien- ride 105 mmol/L, Bicarbonate 25 mmol/L with anion Gap of cephalon, especially pars reticulata of the substantia nigra, 13, Magnesium 2.4 mg/dL, phosphorus 3.6 mg/dL, Glucose and brain stem tegmentum.. These regions are also con-

176 Articles © The authors | Journal compilation © J Med Cases and Elmer Press™ | www.journalmc.org 177 Peduncular Hallucinosis J Med Cases • 2013;4(3):176-178 nected to the pedunculopontine nuclei by efferent pathways follow-up in the outpatient clinic and we lost contact. [9]. Lesions in these areas produce disordered REM sleep, which is linked to dreams. Thus peduncular hallucinations may be similar to dream like activity that is normally sup- References pressed during wakefulness in normal individual. Disruption of ascending impulses from brain stem reticular activating 1. Holroyd S. Visual hallucinations in a geriatric psychia- system is a postulated cause [10] of dream like activity in try clinic: prevalence and associated diagnoses. J Geriatr PH. Whereas Von Bogert described PH as a state of ego dis- Psychiatry Neurol. 1996;9(4):171-175. solution with the loss of the ability to distinguish reality from 2. Wolff HG, Curran D. Nature of delirium and allied imagination [11]. states. Arch Neurol Psychiatr. 1935;33:1175-1215. Initially there was a diagnostic dilemma for our case. 3. Webster R, Holroyd S. Prevalence of psychotic symp- Part of our differential was Charles-Bonnet syndrome [12] toms in delirium. Psychosomatics. 2000;41(6):519-522. for this case. The syndrome occurs most commonly in el- 4. Dunn DW, Weisberg LA, Nadell J. Peduncular halluci- derly presenting with visual impairment. The common con- nations caused by brainstem compression. Neurology. ditions leading to this syndrome are age related macular 1983;33(10):1360-1361. degeneration, followed by glaucoma and cataract. But these 5. Kumar R, Behari S, Wahi J, Banerji D, Sharma K. Pe- are not accompanied by any feature of psychosis, impaired duncular hallucinosis: an unusual sequel to surgical sensorium, dementia, intoxication, metabolic derangement, intervention in the suprasellar region. Br J Neurosurg. or focal neurological illness. Our patient came with altered 1999;13(5):500-503. sensorium. Even though she had ocular pathology relevant 6. Geller TJ, Bellur SN. Peduncular hallucinosis: magnetic neurological, ophthalmological and radiological consulta- resonance imaging confirmation of mesencephalic- in tion directed us towards Peduncular Hallucnosis possibly farction during life. Ann Neurol. 1987;21(6):602-604. due to Glioblastoma multiforme in the pons. 7. Feinberg WM, Rapcsak SZ. ‘Peduncular hallucinosis’ The clinical syndrome of “peduncular hallucinosis” con- following paramedian thalamic infarction. Neurology. sists of formed, vivid, visual hallucinations associated with 1989;39(11):1535-1536. sleep cycle disturbance and cranial nerve palsy. But in the 8. McKee AC, Levine DN, Kowall NW, Richardson EP, Jr. absence of localizing focal neurologic deficits, it is easily Peduncular hallucinosis associated with isolated infarc- confused with delirium or psychosis. When hallucination tion of the substantia nigra pars reticulata. Ann Neurol. dominates the clinical presentation, a patient may be misdi- 1990;27(5):500-504. agnosed as suffering from a psychiatric disorder. Visual hal- 9. Beckstead RM, Domesick VB, Nauta WJ. Efferent con- lucinations typically can be a cause of distress and anxiety in nections of the substantia nigra and ventral tegmental patients. Most of the time these patients are not diagnosed, area in the rat. Brain Res. 1979;175(2):191-217. which leads to inappropriate management and over medica- 10. Jacob A, Prasad S, Boggild M, Chandratre S. Charles tion. It may also cause early institutionalization. Evidence Bonnet syndrome--elderly people and visual hallucina- for pharmacological treatment for peduncular hallucinosis tions. BMJ. 2004;328(7455):1552-1554. is limited. Studies showed that anticonvulsant, serotonergic 11. Kumar R, Kaur A. Peduncular hallucinosis : an unusu- agents, antipsychotics have showed some improvement [11]. al sequelae of medulloblastoma surgery. Neurol India. But treatment with medications depends on patient’s clini- 2000;48(2):183-185. cal condition and symptomatology. Our patient was given 12. Spiegel D, Barber J, Somova M. A potential case of pe- psychoeducation about her illness. She responded well to be- duncular hallucinosis treated successfully with olanzap- side supportive psychotherapy. But unfortunately she did not ine. Clin Schizophr Relat Psychoses. 2011;5(1):50-53.